NCD 240.9 (Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure consequent to COPD) can be located here.
Q: How can suppliers and providers comply with the utilization requirements of NCD 240.9? Is a machine readout necessary that may require software updates?
A: CMS National policy does not state that information supporting the service must be data from the machine. NCD 240.9 states:
…a patient “must be determined by a clinician to use the device at least 4 hours per 24-hour period, on at least 70% of days in a 30-day period”. The term “by a clinician” could refer to documentation a clinician enters into the medical record that would provide support to pay the claim. This could be achieved by the clinician recording in the medical record the amount of time the beneficiary states using the machine and that amount being no less than the NCD requirements.
Q: How would existing patient NIV equipment be handled under the new NCD?
A: Ventilators fall under “frequent and substantial servicing” of the DMEPOS benefit. CMS performs DMEPOS claim reviews using the policy that is in place at the time the item was initially provided. CMS will direct the MACs to focus claim reviews on claims where the initial claim for the item falls after the effective date of the new NCD.
The above does not restrict/limit applicable contractors from performing medical review where there is concern about potential fraud. Additionally, this does not impact the limited reviews that may be randomly conducted by the Comprehensive Error Rate Testing (CERT) contractor, per their statutory obligation.